This following link attempts to make predictions of the big-picture impacts Obamacare will have on the economy. I read the entire thing, and the substance was compelling so I am making a thread. The article is very well-informed, and by outlining these intelligent predictions first, perhaps TSB will incorporate them into new predictions.

- Hospitals will consolidate, some will go under, and high-skilled doctors and nurses will be laid off - Hospitals will use more first and second line workers (low wage), in order to reduce costs per visit - Corporations will use wellness programs from pressure from the pricing structure - Health coverage will ultimately be 3-tiered - Lots of hourly workers will be reduced to <30 hrs/week (not really a prediction any more)

Note that the first 2 come from lower re-reimbursement rates from insurance, to come in line with Medicare-ish rates. This is a compelling argument. That pressures hospitals to schedule doctors in rapid-fire machine-gun sessions. Personnel costs are just too high to sustain the lower reimbursement rates. This detail is much more important than I have ever considered before.

I disagree with the 3rd point, because preventive care hasn't been empirically shown to reduce costs. It only improves quality of life. Employers have insufficient motive to improve employee's quality of life. The ACA has some provisions about reimbursement on the basis of patient, not visit, number. Here is a summary:

Quote :

"Over the next five years we will go from volume-based reimbursement in medicine (based on the number of procedures or patients a provider sees) to a value-based system (being paid the same amount per patient no matter how well or sick she is, so the goal will be to motivate people to stay healthy). This change will result in lower hospital income even as we treat more patients."

I do not understand this. WHO will be reimbursed on the basis of value? Most people I know don't have "a doctor". There is no way to assign responsibility such that the concept makes any sense. Perhaps I've also confused the idea of employer wellness programs with this change. Large employers have always had exposure to their employee's health care costs. I do worry about that. I worry that if an employer considers you to be prone to sickness, then they will limit your ability to work, in fear that you'll be a drag on their insurance bills. But I digress...

I will add my own prediction to the mix:

- people will stop calling it Obamacare

Once he's out of office we won't care. The right-wing will despise the term after 2016. Even if they still hate the ACA, using Obama's name will still be honoring him in a way.

"Note that the first 2 come from lower re-reimbursement rates from insurance, to come in line with Medicare-ish rates. This is a compelling argument. That pressures hospitals to schedule doctors in rapid-fire machine-gun sessions. Personnel costs are just too high to sustain the lower reimbursement rates. This detail is much more important than I have ever considered before.

"

especially considering the massive growth that's going to need to occur in the pcp system to have enough providers to accomodate the massive influx of patients into the system. This will only compound #1

Quote :

"I do not understand this. WHO will be reimbursed on the basis of value? "

this is referring to providers and hospitals, not insurance companies. It's saying that if a doctor performs an endoscopy on one patient, and writes a second patient a z-pack for an infection he will recieve the same reimbursal rate from the insurance companies.

In our current system, hospitals and specialists make varying amounts of money off proceedures. They (the powers that be) are trying to move health care away from specialty care and into primary care. This means that if the doctor in the previous example gets (inc made up numbers) $500 dollars for both patients, instead of $5000 for the proceedure and $50 for the antibiotics visit he will make $5050 instead of $1000. He is, effectively, losing money while seeing the same amount of patients.

This change away from having larger reimbursements for specialized care is going to hammer hospitals especially who depend on massive proceedure reimbursements to stay out of the red.

Also ... preventative health doesn't work in the us because we do not adhere to it ... We still have abstinance only sex ed for god sakes. We play at preventative care, but in general western medicine is a treat the problem not fix the problem modality. If we made a concerted effort at -real- preventative health and education I garuntee it would show dividends

it makes sense that wellness programs are encouraged, because a corporation will be charged based on the total amount of care for all their employees. if they are unhealthy even in the short term, then they have more problems. over a number of years it adds up even more.

a friend of mine works for a company that charges more to people with a very high BMI. they also offer discounts to those with gym memberships who use them regularly, and i think give out free gym memberships.

"A colonoscopy costs $1185 on average. Get that for every 10 years (as recommended by the CDC) for 30 years, that's $4000. Average cost to treat colon cancer according to a study I googled was $29,196."

Wait, are you saying you don't have to treat cancer discovered through a colonoscopy?

Quote :

"Compare the cost of a triple bypass to that of regular physicals combined with a healthy diet and exercise."

I agree with your point in theory, but a) healthy people get heart disease also and b) exercise promotion isn't the same thing as compliance. It really depends on how cost effective it is to tell people what they already know.

"this is referring to providers and hospitals, not insurance companies. It's saying that if a doctor performs an endoscopy on one patient, and writes a second patient a z-pack for an infection he will recieve the same reimbursal rate from the insurance companies.

In our current system, hospitals and specialists make varying amounts of money off proceedures. They (the powers that be) are trying to move health care away from specialty care and into primary care. This means that if the doctor in the previous example gets (inc made up numbers) $500 dollars for both patients, instead of $5000 for the proceedure and $50 for the antibiotics visit he will make $5050 instead of $1000. He is, effectively, losing money while seeing the same amount of patients."

Enlightening. But this all seems pretty extreme. I don't believe our system is ready for a change like this. There must be so many requisite changes made before we can seriously talking about a system like this.

And would your hospital start offering you wellness programs? I return to my claim that most people don't have "a hospital". You generally go to whichever hospital is most convenient. If you walk in the door, and then the hospital gets paid based on whatever your condition is, then the hospital has incentive to over-diagnose and under-treat.

BCBSNC is actively working on this in NC and I know one large hospital in the western part of the Triangle that is actively pursuing this. And while you are right most people don't choose a hospital, hospital systems are diversifying into the practice field too. Many hospitals now own/manage a Physician Network where they actually handle individual clinics outside of the "hospital" environment. This is a mutually advantageous arrangement, as it gives the doctor an association with a large system and they handle a lot of the staffing, office management stuff. On the other side they get almost exclusive referrals from that clinic/doctor, so it brings them in more business. One area that is tougher to manage is that the doctor usually gets a salary, so whether he sees 12 patients a day or 50, he makes the same amount. They approach this with performance matrices for bonus pay, so that the doctor who does more business and brings in more profits for the physicians network will be the one making more.

As for "community care" which is what its referred to locally, there is still a lot of exploration and debate going on about it. On the one hand they are getting paid a flat rate to handle these patients, so it may cost them more if that patient does need a more expensive procedure, they do not have to worry about unsteady pay. The insurance company strokes them the same check for the community of patients a month, and you do not have to worry as much about nonpayment from the patients portion for a super expensive procedure. So while they lose some on the big procedures, which are expensive for the hospital to perform, they make out in the large number of patients they are "servicing". Obviously if they can get their patients healthier and to be proactive on their health, then the costs for this decrease for both the patients and the hospital as well. So with a lot of the unstability of Medicare/Medicaid payments, the dearth of uninsured patients, etc larger hospital systems are very interested in this format. Smaller hospitals without a larger hospital network affiliation who cannot offer all of the services would not benefit in this approach and would probably lose out big time. But Wakemed, UNC, & Duke would likely embrace something like this.

"Average cost to treat colon cancer according to a study I googled was $29,196."

That's it? $29k to treat colon cancer sounds really really low.

For the longest time I didn't have "a doctor" but since around when I turned 30 I have. I have a primary care doctor and an orthopaedic doctor/surgeon as well. And my hospital of choice is WakeMed West in Cary off Tryon Road.

"I do not understand this. WHO will be reimbursed on the basis of value? Most people I know don't have "a doctor". There is no way to assign responsibility such that the concept makes any sense."

So the entire goal is to move healthcare providers away from quantity to quality. Like right now if a patient goes in and out of the hospital with a chronic, but manageable, condition and the hospital just treats the symptoms without getting them to manage their condition, the hospital gets paid for every readmission. If the hospital fucks up and the patient gets readmitted, the hospital gets paid again. they have no motivation, beyond any sense of empathy, to really improve the patient's quality of life.

So the way they are going to try to solve this, is by creating what are called Accountable Care Organizations. Groups of providers sign up to create an ACO under Medicare. They get assigned a chunk of patients and they get paid based on the number of patients. However, those payments vary based on the quality of care those patients get. So if an ACO maintains a high quality of care for their entire population, they get more money. If they do poorly, they get penalized. Since they are no longer getting paid per transaction, it moves the focus from "get them in the hospital so we get paid as much as possible" to "keep them out of the hospital so we save as much as possible".

The penalties gradually increase over time which should allow for plenty of time to start fixing these problems. Its been well known for years that decreasing readmissions by following up with patients after visits is a fantastic place to reduce costs and increase quality, but up until now doing so has run counter to the hospitals making money. Now their payment situation is reversed so the focus will be quality instead of quantity.

In the long term, and I've talked about this before, the real solution is to start bringing process controls and real quality management systems into healthcare. I mean its pretty obvious. Without those internal controls theres no way to know whats going on inside your organization and you cant guarantee quality outcomes. Manufacturing learned this decades ago, and now its healthcare's turn.

"Groups of providers sign up to create an ACO under Medicare. They get assigned a chunk of patients and they get paid based on the number of patients. However, those payments vary based on the quality of care those patients get. So if an ACO maintains a high quality of care for their entire population, they get more money."

But these ACOs would want to get assigned healthy people. It seems like the best way to make money would be to encourage healthy people in your area to sign up.

Maybe this gets closer to my gap in understanding. Perhaps this system would only apply to patients who have a condition and are receiving continuing care? That would make more sense, but there would still be a strong cohort effect. Would there be a "market price" for a certain population in a certain area?

The ACOs don't get to pick and choose patients cause yeah that wouldn't work. They're assigned patients by medicare afaik.

I don't know the specifics on pricing but i'd be willing to bet its regional based on past pricing models.

Since the laws only specify that the quality of the population must meet certain metrics, instead of how or who to target, it seems pretty obvious that the first groups providers will target are the chronically-ill, as you note. These people are mostly older and they use the most care AND are the largest drag on quality metrics. Its one very good starting point.

The next target would probably be adjusting internal processing of common acute cases to reduce waste, but that's just a guess on my part.

Theoretically they could do multiple things at once, but irl hospitals are really poorly run and theres so much momentum in existing processes that they take a lot of effort to change.

"These people are mostly older and they use the most care AND are the largest drag on quality metrics. Its one very good starting point."

Ok that makes sense.

FWIW, the article goes into some detail about lower back pain as an example. It's a very common case, and generally the people who have it respond well to the same therapies. So instead of the hospital shuffling their feet through many appointments, it's better to get some lower-wage worker to quickly get into the method they know works. The argument is they could cut costs.

That's a nice idea. I think there's certainly room for improvement on these conditions that so many people share. If you're one out of literally millions who have basically the same kind of affliction, then the health care system would be terribly neglect to not have a streamlined process ready for you!

The entire value of doctors is supposedly that they can think critically about medical issues.

exactly. the majority of cases are very boring and easily diagnosed and treated. but since the outliers are always more exciting, that's what the media and politicians bring up when they talk about reforms cause people are morons and want to hear about the flashy thing.

saving $5 on a boring procedure that's done 10 million times a year is obviously better than saving $100 on something done a thousand times a year. I mean the rarity of those cases is one of the primary reasons they cost so much. so trying to fix the costs for those outliers first (or worse designing the entire system around them) is extremely silly.

cut costs on the most common procedures that affect the most people and then use what you've learned there to hit the next common procedures and so on and so forth. another thing you're gonna find is that even if you're focusing on one specific chronic problem some of the fixes are immediately going to improve all hospital function. ex: if you're focusing on making sure your nurses handle pneumonia discharges properly that training is going to bleed over into every discharge they do.

this is all kind of exciting cause theres such a good chance that it works in the long term.

We have much ado about the fact that premiums will be further equalized between people of different age groups and family sizes. There is some provision that prevents the most expensive plan from being some multiple of the less expensive plan. But yet, we haven't seemed to decouple health insurance from employment.

So in the open marketplace, prices are rising for young people and decreasing for the 60 year olds. Do employers see this effect? They have, and will continue to, pay more for the health care plan for older workers, but will that be less now? Or are those rules not going to be the same on the employer side?

" There is some provision that prevents the most expensive plan from being some multiple of the less expensive plan."

Which is easily one of the most retarded ideas in the entire bill. The biggest problem with health insurance is that it is not behaving like insurance; it's behaving like a group savings plan, which is a horribly inefficient way to pay for damned near anything. The end result of this provision is that the cheapest plans will become more expensive, as we are already seeing. The insurance companies will love this, because the cheap plans are generally consumed by healthy people, which means the insurance companies make a killing providing the same product to the same people, only they can now charge more thanks to the gov't!

Add to this the fact that you will invert the traditional way that insurance works, namely charging people who are higher risks more and lower risks less. In a sane world, riskier people pay a higher rate in proportion to their risk than less risky people, which works beautifully; it costs more and more, with respect to the amount of risk, to be riskier. This would give people an incentive to take better care of themselves, as they would not be able to afford premiums or out of pocket expenses. Instead, in this brilliant system, it's regressive. Those with the smallest risk pay the most in proportion to their amount of risk and vice versa. There's no incentive, monetarily, to limit risky behaviour.

And the best part for the insurance companies? By the time it comes time to pay the piper on risky behaviour, the insurance can shift the cost over to the federal gov't via Medicare, because people will be really starting to see the effect of their decisions right about when Medicare kicks in. Some will hit the wall sooner, but most will likely hit it in their 60s. Meanwhile, the insurance companies have taken all the higher premiums on the person when they were younger and they run off fat dumb and happy, while the gov't gets stuck with a sick person to actually pay for.]

Employers shouldn't have anything to do with their employees' health in the first place (aside from not making it needlessly worse via shitty working conditions), so such a prognostication is worthless as it is.

"Employers shouldn't have anything to do with their employees' health in the first place (aside from not making it needlessly worse via shitty working conditions), so such a prognostication is worthless as it is."

the benefits to having healthy employees should be apparent

unless you mean that healthcare shouldn't be tied to employers, in which case i'd agree (but probably for a different reason).

"It does sound low. I had an appendectomy with a ~14 hour stay not too long ago, and I was billed $35k (before insurance of course)!"

LOL, yeah that's exactly why I made that comment. When I had an appendectomy last year I was in the hospital for roughly 20 hrs and the invoice was around $26k (of which insurance paid everything minus my $75 ER copay).

It wouldn't take much for ACA to evolve into something people can gladly get behind.

Eliminate the employer mandate but incentivize former health benefits as compensation, bolster the exchanges, add a public option, close the loophole for subsidies for poor, and you have a program people might be proud of.

The Supreme Court upheld the individual mandate on the grounds that the penalty for not being insured was actually a tax as I understand it (correct me if I'm getting any of this wrong). But I was also under the impression that the Court can not rule on whether a tax is constitutional until someone has had to pay it. If this is the case, is it possible the ACA could be challenged again once this happens?

"So the entire goal is to move healthcare providers away from quantity to quality. Like right now if a patient goes in and out of the hospital with a chronic, but manageable, condition and the hospital just treats the symptoms without getting them to manage their condition, the hospital gets paid for every readmission. If the hospital fucks up and the patient gets readmitted, the hospital gets paid again. they have no motivation, beyond any sense of empathy, to really improve the patient's quality of life.

"

Just as an aside.

This is untrue. These patients are referred to as "Bouncebacks." Or people who return in a given time to be treated for the same problem (usually admissions are looked at closest, with the time frame being 30 days).

Bounceback rate is monitored by a number of regulatory agencies and if your bounceback rate is too high you can be fined and/or lose government funding and medicare/medicaid reimbursement.

Having bouncebacks are inevitable, but having a high number is very bad for a hospital.

"The Supreme Court upheld the individual mandate on the grounds that the penalty for not being insured was actually a tax as I understand it (correct me if I'm getting any of this wrong). But I was also under the impression that the Court can not rule on whether a tax is constitutional until someone has had to pay it. If this is the case, is it possible the ACA could be challenged again once this happens?"

The latter bit has to do with the Anti-Injunction Act, and the Supreme Court ruled that for that interpretation, you need to look at whether Congress called it a tax, because the Anti-Injunction Act was also written by Congress; the former has to do with the Congressional power to tax, and the Court ruled that for the interpretation of that Constitutional provision, you need to look at whether it functions like a tax, and it went through a bunch of ways in which the "shared responsibility payment" (formal name for the penalty undergirding the "individual mandate") functions like a tax, and how it differs from some other penalties found to be unconstitutional, even ones that were called taxes (like a Wilson-era tax on child labor, which in a very un-tax-like manner was collected by the Labor Department rather than the IRS, and even then only on those who "knowingly" took an action to trigger the tax, while taxes are normally imposed on people whether they were aware of their obligation to pay or not).

"When it's law that everyone must by insurance, this isn't going to fly, and that's when the public option will be politically viable."

So when are we going to stop pretending that progressive/liberal support for the ACA wasn't about breaking the system to the point of complete uselessness, and then leveraging widespread suffering/death for "real" health care reform?

Pretty much every progressive disliked the ACA decrying it as a handout to the insurance companies.

Back in the days when the Republicans filibustered the ACA and negotiated OUT the public option (then subsequently didn't vote for the bill they crafted), Obama had to give that speech about not letting the good be the enemy of the great (he's used this line several times since his candidacy).

Setting minimums standards for coverage and predictable payouts to health providers, expanding health care subsidies, and creating health exchanges are all good ideas.

The employer mandate needs tweaking, and the individual mandate without a public option is crooked. I wouldn't say this is breaking the system, but Rome wasn't built in a day. Overall it's an incremental advancement, far from broken to uselessness or heralding death. That's a paranoid delusional expectation of what to expect.